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Expanding the HIV hunt

Doctors are urged to make screening routine for most, not just high-risk, patients.

December 08, 2008|Jill U. Adams | Adams is a freelance writer.

On World AIDS day last week, the American College of Physicians announced new practice guidelines that call for doctors to encourage all of their patients to be tested for HIV. They join other doctor groups in endorsing a federal Centers for Disease Control and Prevention recommendation that everyone ages 13 to 64 be screened for HIV infection.

HIV is the virus that causes AIDS, and the most recent CDC data suggest that more than 1 million Americans carry the virus, including more than 50,000 who were newly infected in 2006. That year, the CDC devised its new "opt out" strategy for HIV testing. The next time you see a doctor, whether for a physical exam or a specific complaint, he or she may say, "Let's test your blood for cholesterol, glucose and HIV." In the past, the HIV screening suggestion would have been limited to high-risk patients such as intravenous drug users and gay and bisexual men.

Why the change? For starters, the previous approach too often failed to identify new infections, says Dr. Bernard Branson, of an HIV/AIDS prevention division at the CDC, who was instrumental in developing the current recommendations. For example, a CDC project on emergency room admissions showed that when the decision to screen for HIV was based on a patient's profile, one out of two infected people were not identified.

In addition, recommending the test for everyone circumvents a cumbersome and often awkward conversation between doctors and their patients. Under the old system, doctors had to ask a host of sensitive questions simply to determine if a person fell into one of the high-risk groups that should be tested, an uncomfortable and time-consuming task. Now, rather than asking about their patients' sex lives, doctors can recommend testing as routine medical care.

Why should teenagers and married women, to name two traditionally low-risk groups, be screened for HIV status? Because, increasingly, HIV is transmitted through heterosexual contact, Branson says -- and also, because patients can benefit. It's known that as many as one in four people who are infected with HIV don't know it -- but it's also known that therapy works best when it is started before a patient shows symptoms of AIDS.

Thus, people who are identified as HIV-positive early and get medical treatment can delay their progression to AIDS and live longer.

And, AIDS researchers say, that knowledge can blunt the spread of the disease. A CDC study, published in the journal AIDS in 2006, suggests people who know they have HIV engage in fewer risky behaviors than people who are unaware of their HIV status. In addition, modern drug therapy keeps the viral load down, which means it's less likely the virus will be transmitted should risky sexual contact occur.

Some hurdles to universal HIV screening are falling away, such as questions about who pays for the test. California, for example, requires health insurers to cover testing costs. Also, fewer states require counseling and written informed consent before blood is drawn, steps that complicate testing and can delay diagnosis.

Other hurdles -- such as discomfort in talking about sex -- may be slower to fade.

Even though doctors have been relieved of having to ask men if they have sex with men, or to ask women if they're IV drug users, they still may hesitate to offer the test, says Thomas Coates, who directs the global health program at the UCLA David Geffen School of Medicine. "It may open up a discussion that the physician feels he or she doesn't want to get into or doesn't have time for or doesn't have training for," such as a patient responding, "What, you think I'm gay?" And, Coates says, if the test does come back positive, who's going to do the counseling and referring? Who's going to notify partners? "It's not without its labor-intensiveness," he says.

Coates, who counsels physicians on how to broach delicate issues, adds that it's important to raise the issue even without an in-depth, follow-up discussion. Simply recommending the test signals to patients that it's important for health, he says.

Screening teenagers may be even more challenging. When Branson and his CDC colleagues were developing the recommendations, they considered screening only sexually active teenagers. "But because they often come in with their parent, [teens] may not want to acknowledge that," he says. Screening everyone defuses such charged situations.

Again, says Coates, acknowledging that HIV exists in our world delivers an important health message to teens. "If a physician is raising the issue of having an HIV test, it's kind of a signal to the adolescent that this is something that he or she needs to think about," he says.

Adds Christina Elston, managing editor at L.A. Parent magazine, "This is a health issue. It isn't a sex issue. I think parents confuse that."

To learn your HIV status, go to your regular doctor or visit a clinic that offers free and confidential testing. Clinics in Los Angeles County can be found at www.lapublichealth .org/std/clinics.htm or by calling the STD hotline at (800) 758-0880.


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